Anxiety, Stress and the Heart

The American Psychological Association (APA) defines anxiety as “an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure.” https://www.apa.org/topics/anxiety/

The impact of anxiety and chronic stress on cardiovascular health has been studied less frequently than the impact of depression.  Anxiety due to psychosocial stressors has long been linked to hypertension.

According to Richenberg et al. (2020) elevated anxiety levels can worsen symptoms in patients with heart failure and increase the frequency of hospital readmission.

Anxiety can result in autonomic arousal increasing circulating catecholamines. The development of hypertension and a pro-inflammatory state from anxiety increases the chances of developing coronary heart disease (Chauvet-Gelinier & Bonin, 2017).

Chapa et al (2014) states the following pathophysiologic mechanisms created by anxiety facilitate poorer cardiovascular outcomes:

Tully et al. (2016) conducted a review of studies linking anxiety to hypertension and coronary heart disease. While the studies point to a strong link between anxiety disorders and the development of CVD, a causal effect was not been strongly established.

However, Easton et al. (2015) in a meta-analysis of 38 studies, estimated that 32% of patients with heart failure experience higher than normal levels of anxiety. Johansson et al. (2021) studied 23,000 patients to determine the health-related quality of life (HRQL) and mortality in patients with heart failure. They found the following:

Health-Related Quality of Life (HRQL) is a strong and independent predictor of all-cause death and HF hospitalization across all geographic regions, in mild and severe symptomatic HF, and among patients with preserved and reduced ejection fraction.

Treatment for anxiety

Treatment for anxiety can include medication and/or therapy, as well as social support and exercise. Cognitive therapy, with particular emphasis on non-catastrophic events, is also recommended. Some patients with anxiety disorders will also respond to antidepressant medications. Here are the common medications used to treat anxiety:

Benzodiazepines

Benzodiazepines enhance the activity of the neurotransmitter GABA—a chemical in the brain that helps you to feel calm. Benzodiazepines are recommended for short-term or occasional use, such as fear of flying. They have the potential for abuse and addiction. These are the common ones used:

Selective serotonin reuptake inhibitors (SSRI)

SSRIs work by stopping nerve cells in the brain from reabsorbing serotonin, which is a chemical that plays a vital role in mood regulation. One of the major considerations with these medications is the 2-6 weeks’ time these medications need to take effect.

Examples of SSRIs for anxiety include:

Serotonin-norepinephrine reuptake inhibitors

These medications work by reducing the brain’s reabsorption of the chemicals serotonin and norepinephrine.

Examples of SNRIs for anxiety are:

Tricyclic antidepressants (TCAs), an older class of antidepressant drugs, may reduce anxiety but have many side effects and are not commonly used. https://www.medicalnewstoday.com/articles/323666#types-of-anxiety-medication

Wu et al. (2014) found a reduction in the incidence of MIs in patients taking Benzodiazepines as long as the dose was less than 5 mg. Larger dosages resulted in less favorable outcomes.

Chronic stress

Chauvet-Gelinier and Bonin (2017) state the field of psychobiological theory can help describe the link between psychological factors and physical illness, particularly cardiovascular disease. Cautioning that coping style, personality traits, or social support might modulate the stress response and that chronic stress can increase the allostatic load, the detrimental stress related wear and tear on the body. The researchers described the stress mechanism as:

    1. hyperactivation of the hypothalamic–pituitary–adrenal axis and the autonomic nervous system
    2. dysregulation of blood pressure and cortisol levels
    3. immunoinflammatory response occurring with the production of inflammatory cytokines
    4. metabolic disturbances (glucose and lipid dysregulation), metabolic syndrome and cardiovascular disease.

Stress management

van Montfort, et al. (2015) reinforce that cardiovascular risks occur because of chronic stress. They have found the following to be helpful in reducing stress:

  1. Psychological information
  2. Psychotherapy about stress reduction
  3. Learning coping strategies
  4. Improving cognitive and behavioral strategies

These methods have been found to improve cardiac outcomes, better treatment adherence and rehabilitation adherence (van Montfort, et al., 2015).

Lucetti, et al (2014) also found conscientiousness, openness, and extraversion to be personality characteristics that lead to better chronic stress management. These three characteristics, particularly conscientiousness, lead to better long-range goal production, organizing and planning ways to achieve goals and pushing through difficult times to achieve them.

References

Chapa, D.W., Akintade, B., Son, H., et al. (2014). Pathophysiological relationships between heart failure and depression and anxiety. Crit Care Nurse.34(2), 14–24.

Chauvet-Gelinier, J. C. & Bonin, B. (2017). Stress, anxiety and depression in heart disease patients: A major challenge for cardiac rehabilitation. Annals of Physical and Rehabilitation Medicine. 60, 6–12.

Easton, K., Coventry, P., Lovell, K., Carter, L.A. & Deaton, C. (2015). Prevalence and measurement of anxiety in samples of patients with heart failure: meta-analysis. J Cardiovasc Nurs. 31(4), 367-79. 

Johansson, I., Joseph, P., Balasubramanian, K., McMurray, J.J.V., Lund, L.H., Ezekowitz, J.A. et al. (2021). Health-Related Quality of Life and Mortality in Heart Failure: The Global Congestive Heart Failure Study of 23 000 Patients From 40 Countries. Circulation. 143(22), 2129-2142.

Luchetti, M., Barkley, J.M., Stephan, Y., Terracciano, A. & Sutin, A.R. (2014). Five-factor model personality traits and inflammatory markers: new data and a meta-analysis. Psychoneuroendocrinology 50, 181–93.

Rechenberg, K., Cousin, L. & Redwine, L. (2020). Mindfulness, Anxiety Symptoms, and Quality of Life in Heart Failure. J Cardiovasc Nurs. 35(4), 358-363.

Tully, P. J., Harrison, N. J., Cheung, P. & Cosh, C. (2016). Anxiety and Cardiovascular Disease Risk: A Review. Curr Cardiol Rep. 18, 120.

van Montfort, A., Meyer, F.A., von Kanel, R., Saner, H., Schmid, J.P. & Stauber, S.  (2015). Positive affect moderates the effect of negative affect on cardiovascular disease-related hospitalizations and all-cause mortality after cardiac rehabilitation. Eur J Prev Cardiol 22, 1247–53.

Wu, C. K. et al. (2014). Anti-anxiety drugs use and cardiovascular outcomes in patients with myocardial infarction: a national wide assessment. Atherosclerosis. 235(2), 496-502.

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